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N� <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT I24"� <br /> FO OFFICE USE: V 1601 E. Hazelton Ave. , Stockton, Calif. WI/V <br /> Telephone: (209) 466 -6781 �g� �°� �'�"��' 6� <br /> APPLICATION FOR WELT, CONSTRUCTION OR PUMP PERMIT Permit No. �a <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued / 7.z- <br /> (Complete In Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct <br /> and/or install the work herein described. This application is -made in compliance with San Joaquin <br /> County Ordinance No. 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION 9 ¢,"F4( <br /> CENSUS TRACT <br /> Owner's Name [��i & —' Phone <br /> - _Sr 54,E-J <br /> Address City sir. <br /> 1 ..� .. <br /> Contractor's Name `" License #A . done 1 � % <br /> fi - _., <br /> TYPE OF WORK (Check) : NEW WELL / DEEPEN /_T RECONDITION /_7 DESTRUCTION /_7 <br /> PUMP INSTALLATION / PUMP REPAIR / / PUMP REPLACEMENT /_7 <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES PIT PRIVY <br /> SEWAGE DISPOSAL FIELD CESSPOOL/SEEPAGE PIT OTHER <br /> 0 <br /> INTENDED USE TYPE OF 6 <br /> — _ CONSTRUCTION SPECIFICATIONS <br /> _ Industrial Cable Tool. ,Dia, of Well ,Excavation <br /> Domestic/privatee Drilled Dia, of Well Casing <br />! Domestic/public Driven '' Gauge of Casing T <br /> Irrigation r ..� Gravel Pack Depth of Grout Seal <br /> Other Rotary Type.of Grout <br /> y-M <br /> Other,,' "rQthther ..Informatian <br /> PUMP INSTALLATION: Contractor <br /> Type ,of Pump i i tr H.P. <br /> PUMP REPLACEMENT-. State� Work Done AlaPUMP REPAIR: / / State Work Done ' <br /> ESTRUCTION OF WELL: Well Diameter <br /> Approximate Depth ; <br /> Describe Material and Procedure <br /> 4 <br /> I hereby agree to comply with-all laws and regulations of the San Joaquin Local Health District <br /> and the State -of California pertaining to or regulating well construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will furnish the San Joaquin Local Health District a <br /> WELL DRILLERS REPORT of the well and notify them before putting the well in use. The above . <br /> information is. true to the best of my know a and,beTi f. <br /> SIGNED _ r i TLE <br /> (DRAW P PLAN ON REV SE SIDE <br /> F EPARTMENT USE ONLY F <br /> PHASE I <br /> APPLICATION ACCEPTED BY <br /> DATE ,___6 ^� <br /> ADDITIONAL COMMENTS: <br /> PHASE II GROUT INVECTi N `' <br /> PHASE AIT/FINAL AIT/FINALINSPECTIQ <br /> INSPECTION BY DATE INSPECTION BY DATE 7 <br /> CALL FOR A GROUT INSPECTION .PRIOR TO GROUTING AND FINAL. INSPECTI <br /> E H 142 ' <br />—-- . Ir 7/72 1M <br />